Management of urethrovaginal fistulae

HEAL Africa score to predict failure of surgical repair of obstetric urethro-vaginal fistula in the Democratic Republic of the Congo

INTRODUCTION

Obstetric fistula (OF) repair surgery aims to restore the anatomical and functional integrity of the urinary tract, allowing affected women to regain their dignity and quality of life. However, in some cases, this surgical repair may fail. The objective of this study was to develop a predictive score to identify factors associated with the failure of surgical repair of obstetric urethro-vaginal fistula (FSROUVF) in the Democratic Republic of the Congo (DRC).

METHODS

This is an analytical cross-sectional study of 358 patients with obstetric urethro-vaginal fistula (OUVF) who received surgical repair. We conducted bivariate and multivariate analyses. Score discrimination was assessed using the receiver operating characteristic (ROC) curve, C-index, and score calibration according to the Hosmer-Lemeshow test.

RESULTS

Surgical repair of OUVF failed in 24.86% of cases (89/358). After logistic modelling, 6 criteria predicted FSROUVF: the use of intravaginal indigenous products (AOR = 3.59; 95% CI: 1.51-8.53), the presence of fibrosis (AOR = 6.37; 95% CI: 1.70-23.82), the presence of 2 or more fistulas in the same patient (AOR = 7.03; 95% CI: 3.14-15.72), the total urethral damage (AOR = 3.29; 95% CI: 1.36-7.95), the fistula size > 3 cm (AOR = 5.65; 95% CI: 2.12-15.01), and the postoperative infection (AOR = 351.10; 95% CI: 51.15-2409.81). A score of 0 to 14 was obtained, with a value ≤5 points indicating a low risk of FSROUVF, a value between 6 and 8 indicating a moderate risk, and a value ≥9 points corresponding to a high risk of FSROUVF. The area under the ROC curve of the score is 0.938 with a sensitivity of 60.67%, a specificity of 96.28%, a positive predictive value of 84.38%, and a negative predictive value of 88.10%.

CONCLUSION

We report a FSROUVF rate in the DRC approaching a quarter of operative patients. Predictors of failure included fibrosis, presence of 2 or more fistulas, total urethral involvement, fistula size greater than 3 cm, postoperative infection, and use of intravaginal indigenous products. These factors are constitutive of the HEAL Africa score, which once validated, may have value in pre-operative counselling of patients. This study could be valuable for policy and strategies to address the problem of OUVF in the DRC and in resource limited settings more generally.

Congenital Urethrovaginal Fistula with Blind-Ending Vagina in a Female Pseudohermaphrodite Dog with Urinary Incontinence

An 8 mo old male Doberman pinscher was referred for investigation of persistent urinary incontinence. Physical examination revealed urine leakage and abnormal external genitalia. A computed tomography scan identified a large fluid-filled cavity extending from the caudoventral abdomen displacing the colon and urinary bladder. No retained testicles were identified. A retrograde urethrogram study found a linear communication, cranial to the pubic brim between the urethra to the fluid-filled cavity (fistula). Exploratory celiotomy was performed, and an entire female reproductive tract with a blind-ending vagina and a urethrovaginal fistula was found. En bloc gonad hysterectomy was performed, the fistula was transected, and a careful urethral reconstruction was performed. The urinary incontinence resolved immediately after surgery, and no complications were reported. Mild urinary incontinence recurred 4 days following patient discharge, and a urine bacterial culture was positive for Klebsiella spp. An antibiotic course was prescribed, and the incontinence fully resolved. Congenital urogenital abnormalities should always be considered in young animals presenting with urinary incontinence. Here, a young female pseudohermaphrodite dog with a naturally occurring congenital urethrovaginal fistula is described. Exploratory surgery was required for definitive diagnosis and surgical intervention yielded a good medium-term outcome with resolution of clinical signs.

Repair of Iatrogenic Urethral and Bladder Neck Injury Due to Missed Diagnosis of Mayer-Rokitansky-Küster-Hauser Syndrome

Mayer-Rokitansky-Küster-Hauser syndrome is a congenital malformation disorder resulting in agenesis of the proximal vagina, absence of cervix, and variable development of the uterus. This report describes the repair of a complex iatrogenic urethrovaginal injury due to a missed diagnosis of Mayer-Rokitansky-Küster-Hauser. Our treatment utilized a primary urethroplasty through a transvaginal approach with bladder neck reconstruction and a Martius flap for secondary coverage. Urinary continence was restored postoperatively.

Spectrum of urologic complications in obstetrics and gynecology: 13 years' experience from a tertiary referral center

OBJECTIVE

To analyze the patterns of presentation and management for urologic complications of obstetrics and gynecology in the form of genitourinary fistulas at a tertiary referral center and highlight the social issues associated with them.

MATERIAL AND METHODS

We conducted this retrospective study analyzing 311 patients with genitourinary fistulas after obstetric and gynecologic surgeries between January 2005 and January 2018. We recorded the patients' characteristics and area of residence and then analyzed the etiology, surgical management and success rates by grouping the patients into four types of genitourinary fistulas. The primary end point of success was patient being leak free.

RESULTS

Majority of patients (90.4%) were from rural areas. The distribution of genitourinary fistulas in descending order was vesicovaginal (79.7%), ureterovaginal (11.8%), urethrovaginal (10.2%) and vesicouterine fistulas (2.6%). The mean time to presentation was 25.80±48.69 days with a wide range of 10 days to 360 months. The most common etiology was obstructed labour (58.5%) followed by abdominal hysterectomy (32.7%). For vesicovaginal fistulas the route to be used for repair depended on surgeon's preference and both transabdominal and transvaginal routes had almost equal success rates. The success rate of laparoscopic vesicovaginal fistula repair was 89.4% and all (100%) laparoscopic ureteroneocystostomies were successful.

CONCLUSION

Genitourinary fistulas especially due to obstructed labour are still common in developing world showcasing the problem of inequitable distribution of healthcare. The surgical treatment approach depends on the surgeon's familiarity with the said procedure although versatility is required.

Concomitant repair of stress urinary incontinence with proximal urethrovaginal fistula: Our experience

INTRODUCTION

Proximal urethrovaginal fistula (UVF) located close to the bladder neck may cause extensive sphincter damage and is usually associated with continuous incontinence, which may mask the associated stress urinary incontinence (SUI). Simultaneous correction of SUI avoids a second surgery for SUI, which needs dissection in ischemic fields and carries a high risk of failure. The aim of this study is to describe our technique of concomitant repair of SUI with proximal UVF and our results.

METHODS

Between July 2010 and August 2014, 14 patients underwent UVF repair in Jackknife position by the interposition of a Martius flap and simultaneous correction of SUI by modified McGuire pubovaginal autologous fascial sling. The procedure was carried out a minimum of 3 months of presentation and after detailed preoperative evaluation.

RESULTS

After a mean follow-up of 28 months, all 14 patients were continent. None of the patients developed recurrence of the UVF. Two patients presented with retention immediately after catheter removal and clean intermittent catheterization training was given to both of them. Two patients became pregnant during the follow-up period and were advised cesarean section near term.

CONCLUSIONS

Repair of proximal UVF and correction of SUI can be performed in the same session to avoid the operation in an ischemic field.

A neglected shelf pessary resulting in a urethrovaginal fistula

Vaginal pessaries are safe, simple and effective treatment for pelvic organ prolapse. However, they must be fitted and followed-up correctly as serious complications can arise when pessaries are neglected. In this case report, we present the first reported case of a urethrovaginal fistula due to a neglected shelf pessary.

Rectourinary fistula after radical prostatectomy: review of the literature for incidence, etiology, and management

Although rectourinary fistula (RUF) after radical prostatectomy (RP) is rare, it is an important issue impairing the quality of life of patients. If the RUF does not spontaneously close after colostomy, surgical closure should be considered. However, there is no standard approach and no consensus in the literature. A National Center for Biotechnology Information (NVBI) PubMed search for relevant articles published between 1995 and December 2010 was performed using the medical subject headings “radical prostatectomy” and “fistula.” Articles relevant to the treatment of RUF were retained. RUF developed in 0.6% to 9% of patients after RP. Most cases required colostomy, but more than 50% of them needed surgical fistula closure thereafter. The York-Mason technique is the most common approach, and closure using a broad-based flap of rectal mucosa is recommended after excision of the RUF. New techniques using a sealant or glue are developing, but further successful reports are needed.

Lower urinary tract fistula: the minimally invasive approach

PURPOSE OF REVIEW

A variety of fistulas occur involving the lower urinary tract with adjacent organs namely the vagina, uterus, rectum and colon. Most of these arise out of surgical complications and contribute significantly to the morbidity of the procedures. Surgical reconstruction remains the mainstay in the management. This article reviews the use of minimal-access procedures in reconstruction of lower urinary tract fistulas focusing on the bladder.

RECENT FINDINGS

Recently, numerous reports of laparoscopic and robot-assisted surgical repair of these fistulas have shown that these techniques can be used with efficacy and safety with added advantages of short hospital stay, reduced morbidity associated with surgical incision and lower blood loss. Robot-assisted surgery has the advantage of facilitating intracorporeal suturing, making laparoscopic reconstruction easier. However, the steep learning curve and the high cost of robotic surgery are limiting factors.

SUMMARY

Prevention of lower urinary tract fistula requires improvement in the quality and technique of surgery and minimizing surgical errors. Minimal access procedures offer surgical treatment with low morbidity but with higher cost. Open surgical repair is being used widely for treating these fistulas at this time, worldwide.